Provider Demographics
NPI:1952342107
Name:RIDGE MEDICAL CENTER
Entity Type:Organization
Organization Name:RIDGE MEDICAL CENTER
Other - Org Name:FREDERICK R RIDGE, MD
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-847-4481
Mailing Address - Street 1:RR 1 BOX 1002
Mailing Address - Street 2:
Mailing Address - City:LINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47441-9497
Mailing Address - Country:US
Mailing Address - Phone:812-847-4481
Mailing Address - Fax:812-847-0197
Practice Address - Street 1:RR 1 BOX 1002
Practice Address - Street 2:
Practice Address - City:LINTON
Practice Address - State:IN
Practice Address - Zip Code:47441-9497
Practice Address - Country:US
Practice Address - Phone:812-847-4481
Practice Address - Fax:812-847-0197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200062690AMedicaid